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piles, anal Fissures & Fistula

A man in a white shirt holds on to the a

Anal canal is the last part of the digestive system, which ends at the anal verge

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The mucosa (inner layer) of the anal canal is pain sensitive (below the dentate line), so any pathology in this area may be associated with significant pain & discomfort to the patient

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Piles, anal fissure and fistula are the common benign conditions 

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Pain, bleeding per rectum and pus discharge are the common symptoms of anal canal disorders

 

Since rectal & anal cancers may present with these symptoms, benign conditions should not be confused with malignancies (cancers), which leads to delay in treating cancer

piles(hemorrhoids)

Piles (Hemorrhoids) 

  • Piles or hemorrhoids are the normal vascular cushions present in the anal canal, which helps in maintaining anal continence (control of stool passage)

  • When they enlarge in size giving rise to symptoms such as bleeding, pain etc. become disorders

What are the types of hemorrhoids?

  • Internal hemorrhoids - originate above the dentate line

  • External hemorrhoids occur below the dentate line

  • Mixed component hemorrhoids can occur both above and below the dentate line

Aim of treatment?

  • Since straining at stools  & hard stools are  the major risk factor, medical management is mainly aimed at stools softening

What are the risk factors for piles?

  • Prolonged straining at stools / chronic constipation

  • Low-fibre dietary intake

  • Pregnancy

  • Advanced age

  • Patients on anticoagulation or anti-platelet therapy

What are the symptoms of hemorrhoids?

  • Pain less bleeding

  • Prolapse of piles mass

  • Mucus discharge

  • Severe pain in case of thrombosis of external hemorrhoids

What is the initial medical management?

  • Since straining at stools is the major risk factor, medical management is mainly aimed at stools softening

  • Implementation of fibre and increased liquid intake

  • Avoiding prolonged sitting or straining on the toilet

  • Perianal hygiene

  • Stool softener like laxatives

When patient should undergo surgery?

  • Failure of initial medical management

  • Higher grades hemorrhoids ( eg. grade 3/4)

  • Complicated hemorrhoids 

What are the surgical options available for piles ?

  • Band ligation

  • Hemorrhoidectomy

    • Open

    • Stapled

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anal fistula

Anal Fistula

  • Fistula by definition is connection between two epithelial surfaces

  • So, anal fistula is connection between anal canal (mucosa) & the peri anal skin

  • Skin opening is known as external opening and mucosal opening is known as internal opening

Who develops anal fistula?

  • There are glands in the anal canal which opens in the anal mucosa

  • When anal gland gets infected it leads to anal abscess - the consequences may be

    • Complete resolution of the abscess

    • Abscess may rupture into the skin which in turn forms fistula

    • Sometimes surgical drainage in the skin may end up with fistula

What are the symptoms of anal fistula?

  • There may be pus, mucus or small bloody discharge from the external opening

  • Typically patient will have pain at the abscess site, which ruptures with pus discharge followed by pain resolution

Any investigations required for anal fistula?

  • Fistulogram (MR) is done to delineate the site, length and complexity of fistula tract

How to treat anal fistula?

  • Maintaining a local hygiene - sitz bath

  • Antibiotics & analgesics may be needed in acute infections

  • Surgery

What is the aim of surgical treatment of anal fistula?

  • The aim is to remove or obliterate the fistula tract completely with no or minimal damage to anal sphincter 

  • Every procedure has its advantages & disadvantages in terms of completeness of removal, sphincter preservation and recurrence of fistula

What are the commonly done surgical procedures for anal fistula?

  • Fistulectomy - excison of the fistula tract

  • Fistulotomy - tract will be laid open

  • VAAFT ( Video Assisted Anal Fistula Treatment) - It is a novel minimal invasive technique

  • Fistula plug - Obliteration of the tract by using fibrin glue

anal fissure

Anal fissure

  • Anal fissure is a linear wound in the anal canal

  • As lower half of anal mucosa is pain sensitive, any fissure in this region will be painful

  • Commonly, fissure occurs at posterior midline (6'o clock position) however, it can occur at any site

What is the mechanism of anal fissure development?

  • Passage of hard stools may lead to wear & tear effect on the anal mucosa which ultimately lead to fissure formation

What are the symptoms of anal fissure?

  • Pain during defecation

  • Small bleeding, especially at the end of defecation

How to treat anal fissures?

  • Initial medical management (includes dietary & medications)

  • Surgery - if failure of medical management

What is the initial medical management?​

  • Implementation of fibre and increased liquid intake

  • Perianal hygiene - sitz bath

  • Stool softener like laxatives

  • Use of muscle relaxing ointments for local application

What is the commonly done surgery for anal fissure ?

  • Sphincterotomy - dividing the part of length of internal anal sphincter, which decreases the spasm and pain, ultimately leading to healing

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Discussion 

Clinic Address: Mysore

Impulse Medical Center, Near Vidyashrama College, Temple Road, Mysore-570012 

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Clinic Address: Mandya

Sattva Health Care, Behind TVS show room, 100 feet Raod, Mandya -571401 

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